ICD-10 codeassist services

The main reason for the transition from ICD-9 to ICD-10 was greater documentation precision.  However, if the diagnostics is documented by clinicians at a lower level than what ICD-10 supports, it may result in submission of financial claims that are lower.  Such documentation will also cause a patient’s medical record to lack details, resulting in incomplete information for future providers.  In order to help resolve these problems, a clinical decision support (CDS) system can be designed for ICD-10 awareness which improves coding data capture and helps deliver ICD-10 specific clinical documentation improvement (CDI). Here are some highlights from a  recent article published in ADVANCE by Dr. Strongwater.

Why do you need a CDS system for ICD-10?

The biggest advantage of a CDS system is that it rides on top of the EMR system where it can align clinical decision making with evidence based best practices, thus strengthening the documentation at the very moment that it is recorded into the EMR.  With capabilities to align clinical documentation with ICD-10 at the time of recording and alerting clinicians of the chance to utilize more specific ICD-10 codes; the CDS system is a great help to clinicians as it does not require them to memorize and remember the current expanded ICD-10 code set.

The CDI helps in creating a more specific medical record of the patient and allows for submission of a cleaner and complete claim to help the provider with receiving their just dues.

Required CDS capabilities for ICD-10 CDI

In order to be accurate with its CDI, the CDS system must have the ability to not only read, but also interpret structured documentation as well as unstructured free text notes in the patient’s EMR, along with the capability to collect and interpret information coming from test labs and imaging departments.  While the ability to read clinical documentation at the recording stage is important, it is more important for the CDS to analyze this documentation relative to its knowledge of the patient and issue corrections to the clinician in real time.  A great addition would be providing a pop-up suggestion box within the EMR screen, if there is a need for more details or a change in the reimbursable code.  This pop-up box should have the correct code or higher level of detail that can be captured by the clinician from here itself.

One of the biggest advantages of the CDS system is alleviating the need for clinicians to master ICD-10 codes.  However, what would help enhance the system even more would be the ability to generate a report that indicates which documentation suggestions were ignored by the clinician.  Not only would this help the billing department close any ICD-10 gaps that remain, but would also help in procedure improvements and help the facility to adjust to ICD-10 completely.

Value of the CDS system

The EMR which just records and acts as a repository mechanism for a patient’s medical data is elevated to become a real time advisory system by adding the CDS system.  This allows for streamlining the processes, improving patient safety and result in less time taken and lower costs.  The CDS system delivers value by providing suggestions of best practices along with a complete clinical record of the patient, thus delivering quantifiable clinical and operational benefits to the organization.

5 Commonly Used Healthcare Revenue Cycle Management Terms

One of the key components for healthcare providers and facilities, healthcare revenue cycle management can be intimidating and confusing for a lot of people.  Statutory requirements, coding and billing, payments and denials – add to these the various terms and acronyms that are used – and you have a mine-field on your hands.  Given below are five commonly used healthcare revenue management terms along with a short description of what they mean.

Alternative Payment Models

The traditional method of paying healthcare providers through a ‘fee for service’ model, allowed the system to be misused.  Payments under the ‘fee for service’ model were made for any tests conducted or any service provided, at a pre-negotiated rate for each activity.  This created an incentive for healthcare providers to ask patients to undergo tests or services, which they may not have required for their treatment.  A simple example is a patient who comes with a coughing problem – the first tests that could be asked for is a chest X-ray and a complete blood test, which may not be required at all in this case.  In order to put a stop to this financially draining and open to abuse system, alternative payment models have been developed by healthcare reformers.  Creating incentives that favor quality of service over quantity, these models include bundled payments, ACOs and value based reimbursements.

Bundled PaymentsAs the term denotes, this is a single payment covering all services and tests delivered to a patient suffering from certain acute medical conditions, over a specific time period, covering the full episode of care.  One of the key components of this model is the sharing of a single payment by multiple providers for the different services they administer in a single episode of care.  The healthcare reformers believe that this will bring about better and more dynamic relationships between different providers.  Organ transplants, knee and hip replacement and other similar procedures are some of the many services that are being paid by insurers under the bundled payment model.

Accountable Care OrganizationA coming together of different members of the healthcare community like hospitals, testing labs, doctors etc, under a single umbrella to share responsibility and provide care to a population of patients, an Accountable Care Organization(ACO) delivers coordinated care, which can result in a reduction of unnecessary medical tests and services, higher savings for providers and better health outcomes for patients.  Value based payment models tied to quality metrics, create incentives to provide cost effective and quality healthcare.

Value based reimbursementDriven by Medicaid, Medicare and other commercial payers, value-based reimbursement is directly linked to quality of care and patient outcomes.  Under this system, costs related to unnecessary or excessive tests and services shifts back onto the healthcare providers – thus ensuring that they have no incentive to ask for or provide more than what is required.  Healthcare reformers believe that this will eventually result in superior quality healthcare minus the inefficiencies, redundancies and fraudulent services.

Price transparencyConsumers are becoming more demanding about knowing in details how much the treatment would cost, as it would allow them to take better informed decisions regarding their treatment.  With increasingly high deductibles and out-of-pocket copayments, consumers want accurate data about the costs involved in their treatment.  However, in many cases, it becomes difficult for the healthcare provider to offer this data as they need to negotiate with payers on pricing.  An ACO for example, would be dealing with multiple payers and different price variations.  Price transparency is becoming an important aspect of the healthcare industry revenue cycle.  The lack of price transparency will eventually lead to trust issues between everyone involved.  Healthcare reformers feel that price coordination between payers and providers is as important as care coordination – something that can be achieved through Accountable Care.

Benefits of Outsourcing Provider Credentialing And Enrollment Services

Healthcare facilities address the health needs of people and are supposed to treat the sick under all circumstances.  However, for any organization to remain viable and continue to provide services, it needs to be paid for the services provided – fully and in time.  In order to receive their just dues, organizations have to work with various payers, for example payers like Medicare and Medicaid.  Payer enrollment, till a few years back, was not considered necessary by healthcare professionals as important for building their practice.  Today, however, it is not just necessary, but nearly imperative for clinicians to be enrolled with insurance companies.

With the coming into being of the Affordable Care Act, people who were previously without any health insurance, now have access to healthcare coverage.  This, along with the desire and demand of the majority of patients and their families to utilize their health insurance to pay for healthcare services received rather than paying it out of their own earnings, has made it crucial for healthcare providers to enroll themselves with the payers.

Unfortunately, provider credentialing and enrolling with the payers is becoming more difficult with each passing day.  With most insurance panels getting overloaded due to the spurt in membership applications and a lot of them being selective about enrolling providers, the process of enrolling your facility is becoming more challenging.  Under the circumstances, outsourcing your credentialing and enrollment not only looks as an attractive option but also makes financial sense.

Benefits of Outsourcing Credentialing and Enrollment Services:

• Reduces operating costs which can typically be around 30-40%.
• Eliminates errors which could lead to delays in your enrollment.
• Gives you the advantage of getting experts to do the job.
• Allows your staff to concentrate on billing and collections.
• Gives you more time to concentrate on your patients and building your practice.
• Saves you tons of paperwork and hours of frustration.

Remember, enrollment is necessary to remain monetarily viable, however, your practice was started to treat patients.  That is the core competency of your business and anything else can and should be outsourced to allow you maximum time to do what you do best – help sick people get better.

Difference Between Provider Credentialing and Provider Enrollment

Hiring incompetent healthcare providers or allowing them to remain with your facility can lead to increased liabilities in malpractice suits.  In order to ensure that your facility does not suffer from this, it is important that credentialing and enrollment of your providers is managed properly and kept up to date.  Failure to do so can and will have a negative impact on your revenue cycle.  Add to this, the regulatory requirements under which your facility can be at risk of compliance violations.

To ensure that your provider credentialing and enrollment processes are managed properly, it is important to understand the difference between the two.

Provider Credentialing

Credentialing refers to the process of verifying the proven skills, training and education of healthcare providers.  Verification of the providers credentials are done by contacting the “Primary Source”, which has provided the license, training and education.  The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.  Credentialing is also the validation of a provider in a private health plan and the approval to join the network.

Provider Enrollment

Enrollment refers to the process of requesting participation in a health insurance network as a provider.  The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.  Enrollment is also the validation of a provider in a public health plan and the approval to bill the agency for services rendered.

Importance of Provider Credentialing

Provider credentialing dates back to 1000 BC, and has been an important if not critical part of healthcare services.  The process of credentialing has undergone many changes over the centuries; however, the content of credentialing has remained the same – a verification of the education, training, experience, expertise and willingness to provide medical services by the provider.  It was around 1990, that national organizations started which were dedicated to the credentialing of medical providers.  Around the same time, the National Committee for Quality Assurance (NCQA) set guidelines on the process and method of credentialing medical providers.

These guidelines ensure that healthcare providers have undergone stringent scrutiny with regards to their ability and competence, thus making sure that the patients receive the highest level of healthcare.  For a patient, it is assuring and confidence boosting to know that your healthcare provider’s credentials are certified as through the credentialing process, thus ensuring that you are in good and competent hands.  For the provider, it states that their colleagues are held to the same standards as them.  For the healthcare facility, it shows that they value quality care and place the patient’s well being as a primary goal.

It is very important to remember that in today’s world of health insurance and revenue cycles, improper credentialing can lead to delayed or denied reimbursement for services provided.  Worse, it could lead to serious consequences for all concerned in terms of statutory compliance violations, which can result in monetary damages and criminal charges.

Provider credentialing and enrollment has been overlooked as an important component of healthcare management practices for years.  However, their impact on compliance issues and financial aspects to a practice has ensured that these are now key components to any thriving practice.

MedConverge Provider Enrollment and Credentialing Services can help you reduce your on-hold claim values, streamline and standardize administration processes as well as save time while ensuring compliance.  For further information, please contact: info@MedConverge.com

Top 3 Tips for Medicare Enrollment

Medicare enrollment can be very confusing for those enrolling for the first time.  From being aware of the enrollment period to understanding the type of health coverage required; from finding out the various options available to being knowledgeable of the various scams related to Medicare – all this can cause stress and confusion.  Choosing the right plan requires an individual assessment.  A plan that is right for your spouse or friend may not be the right one for you.  It would be a hassle for most to manage two different plans in the same household, but the potential savings make it worthwhile.

Medicare enrollment is automatic for certain groups; for others, it depends on when they become eligible and under what conditions.  You are automatically enrolled if:

• You are receiving retirement benefits when you turn 65.
• You are receiving disability benefits but are still under 65 years of age.

Enrollment in Medicare Part A is automatic for most people at 65 years of age.  However, you can enroll in Medicare Part A and/or Part B manually during your Initial Enrollment Period (IEP) that begins 3 months before your 65^thbirthday.

Keeping in mind the various options that are available and the confusion that the initial enrollment causes most people, here are some tips to help guide you through the process.

Be aware of your Medicare Open Enrollment Period

It is very important to be aware of when you can first enroll in Medicare – missing the date will incur extra costs and fees.  You are eligible for enrollment from 3 months before to 3 months after your 65^th birthday.  For those already enrolled in Medicare, but wishing to change their plan, it can be done during the general Open Enrollment Period from October 15 to December 07.

Understand the different parts of Medicare

Medicare coverage is split into four parts – A, B, C and D, while the supplement plans are known as Medigap.  It is important that you understand each of these parts and their importance.

• Medicare Part A: This covers costs incurred during an inpatient stay at a hospital and includes room and board, general nursing, and medicines. Remember that this does not cover your doctor’s fees.  Also, long-term care hospitalization or skilled nursing facilities are only covered for a limited time.  While Part A does not attract any monthly fee, there are co-insurance costs and deductibles involved.
• Medicare Part B: Covering durable medical equipment and supplies, this also covers fees charged by the physician for both medically necessary and preventive services. However, remember that this coverage attracts a monthly premium, co-insurance costs and an annual deductible.
• Medicare Part C: Known as Medicare Advantage Plans, these are offered by private entities like Blue Shield, Blue Cross and Humana. Structured in a similar manner as HMO and PPO plans, these offer services like dental, eye, hearing and prescription drug coverage along with covering Part A, B and D of Medicare services.
• Medicare Part D: Getting more specific, this plan offered through private health insurance companies covers the costs of prescription drugs. Different plans offer specific lists of drugs that are covered and thus can be tailored to the drugs that you are currently prescribed and using.
• Medigap: To cover the gaps in Part A and B, this policy is offered by private health insurance companies. However, eligibility for Medigap requires enrollment in Medicare Part A and B.  Medigap offers different plans covering different costs.  Labeled Policy A to Policy N, the most comprehensive of the lot is Medigap F.

Find out your health care needs

It is important that you are aware of your health care needs, considering the different options available through Medicare coverage.  You need to be aware of both your current requirements and your probable near future requirements.  Consult with your physician about what could be required in the near future with regard to your health care.  Once you are aware of your needs, choosing the right plan will not be difficult.

Medicare Revalidation in 5 Steps

As per Section 6401 (a) of the Affordable Care Act, all enrolled providers and suppliers are required to revalidate their Medicare enrollment information under the new enrollment screening criteria.

The Revalidation Process

1. Determine which provider is being requested to revalidate
2. View the information checklist
3. Revalidate using Internet-based PECOS or by completing the appropriate CMS-855 application
4. Check your application status

PECOS is the most efficient way to submit your revalidation information.  Using the Internet-based PECOS allows you not only to review information currently on file, but also update and submit your revalidation.  In order to complete your revalidation process, you will be required to either electronically sign the revalidation application or mail the paper certification statement to your MAC after signing and dating the same.  You can also upload any supporting documentation into PECOS or mail it along with your paper certification statement to your MAC.

CMS has implemented several revalidation processing improvements and norms in an effort to streamline the revalidation process and reduce provider/supplier burden, some of which are listed below.

Established Due DatesDue dates will be on the last day of the month (i.e., June 30, 2016, July 31, 2016, August 30, 2016), by which you must revalidate.  Your next revalidation cycles will generally remain on this due date.

Posted Due Dates on Data.CMS.govAs of March 2016, a listing of all of the currently enrolled providers/suppliers is available at:https://data.cms.gov/revalidation.  While DME supplier information will currently not include due dates and is displayed as a blank field, the rest will display a revalidation due date, if they are due for revalidation.  “TBD” (To Be Determined) will be displayed in the due date field for all other providers/suppliers not up for revalidation.  In order to provide sufficient notice and time for the provider/supplier to comply, CMS will post the revalidation due date up to 6 months in advance for each revalidation due date.

Revalidation Due Date Lookup ToolA revalidation due date lookup tool is now available for users.  Users are also provided with the ability to download the entire data set, which can be downloaded in different formats (i.e., CSV, PDF, XLS, XLSX or XML) from:https://data.cms.gov/revalidation.

CrosswalkOrganizations that the individual provider reassigns benefits to; will also be available as a crosswalk at:https://data.cms.gov/revalidation.

Unsolicited Revalidation SubmissionsRevalidation applications submitted by a provider/supplier more than six months before their due date are defined as unsolicited revalidations.  Please do not submit a revalidation application if a due date does not reflect on the file.

Revalidation Notices sent via email/mail2-3 months prior to your revalidation due date, a revalidation notice will be sent by your Medicare Administrative Contractor (MAC) either by regular mail (at least two of your reported addresses: correspondence, special payments and/or your primary practice address) or email (to email addresses reported on your prior applications) reminding you of your due date for revalidation.

Deactivations Due to Non-Response to Revalidation or Development RequestsYour provider enrollment record may be deactivated if your application is received after the due date, or if you provide additional requested information after the due date.  A new full and complete application will need to be submitted by those providers/suppliers who have been deactivated, in order to re-establish their provider enrollment record and related Medicare billing privileges.  While the provider/supplier will maintain their original PTAN, billing will be interrupted during this period of deactivation resulting in a gap in coverage.

Multitude of EHR Notifications Adding To Physician Burnout

It takes just a jiffy to send an online message – compare that to the days gone by, when paper-based systems made sending messages an onerous task.  That is an improvement in our fast paced world today, or is it?  The ease and speed of instant messages has resulted in people sending and receiving far too many messages which take more time and concentration to read, absorb and act upon.  Does the beep of an incoming message break your concentration from the job at hand?  Do you feel compelled to check the message immediately in case it could be something important?  Are you overwhelmed by the large number of messages that you receive?  Do you find these messages interrupting your concentration while you are performing a critical job?  Now, imagine you are a physician treating a patient – and these messages keep breaking your concentration and taking you away from the job at hand.  Working in a hospital is distracting as it is, with the constant flow of patients, doctors, phone calls, emails and paperwork; add to that another level of communications in the form of EHR inboxes and you have added another source of interruption.

According to a study published in JAMA Internal Medicine, primary care physicians and specialists are getting overwhelmed by the large number of notifications from commercial EHR systems, resulting in alarm fatigue.  Alarm or alert fatigue occurs when the large numbers of notifications received by EHR software becomes overwhelming for the healthcare provider.  The study found that physicians spend on an average 66.8 minutes per day processing notifications from EHR use – not a huge amount of time per se, but, these 66.8 minutes are spread across the day, resulting in constant interruptions and break of concentration for the physicians.  Meaningful use requirements and EHR Incentive Programs have resulted in hospitals installing EHR platforms and healthcare providers using more commercial EHR inboxes.

Notifications coming over the EHR include referral responses, test results, prescription refill requests and messages from other healthcare providers.  Any of these notifications could require an urgent or immediate action; and thus the healthcare provider is compelled to look at it the moment it arrives.  The study investigates the methods used by physicians to sort through these large numbers of EHR based notifications to sift out information that is important for quality care.  The researchers cited a previous study conducted by the Department of Veteran Affairs that found alarm fatigue leading to a larger number of occurrences of overlooked test results and missed information.

Analyzing EHR inboxes of 92 physicians at 3 large practices in Texas, the researchers went through 276,207 notifications received during 125 work days.  According to the research, primary care physicians received a mean of 76.9 notifications per day, out of which 15.5 notifications were related to test results.  Compared to this, specialists received only 29.1 notifications with 10.4 related to test results.  The majority of notifications in both cases were from pharmacies or other physicians.  According to the researchers, “Because a single notification often contains multiple data points (e.g., results of metabolic panels contain 7-14 laboratory values), the actual burden and required cognitive effort required of the physicians is likely greater. Strategies to help filter messages relevant to high-quality care, EHR designs that support team-based care, and staffing models that assist physicians in managing this influx of information are needed.”

Vineet Chopra, in a 2014 JAMA article titled ‘Redesigning Hospital Alarms for Patient Safety’ had written, “The consequence of this well-intentioned generalization is epitomized in the din of chirps, beeps, bells, and gongs that typify hospitals today. It is thus not surprising that concerns regarding safety have emerged, even in populations for whom these protective devices were once considered most valuable.”

However, EHR systems offer healthcare providers with a fast and efficient method of conveying information and data – an aspect that can make a huge difference in critical situations.  A proper automated EHR system can decrease the amount of stress faced by healthcare providers, provided they work out a way to balance their EHR use.  The study concludes that improvements need to be developed to make EHR systems more beneficial for both patients and physicians.